Do Not Resuscitate Dnr Form printable pdf download

Withhold/Withdraw Life Sustaining Treatment and Do Not Resuscitate (DNR) Form

Decision-Maker’s Name:

_____________________________ Telephone: _________________________________________

Relationship to patient:

Self

Health Care Agent

Legal Surrogate

Oral or Signed Consent:

Signature: _________________________ Date/Time: _____________________

The patient/decision maker has been fully informed about the medical condition and consents to:

Order for DNR

Order to withhold/withdraw the following other life sustaining treatments

___________________________________________________________________________________________________

Physician Name ________________________________ Signature ______________________

Date_________________

Adult Witnesses

: The decision maker gave oral /written consent in our presence (including patient’s oral prior decision if applicable).

Witness’ Name______________________________ Date_________________

Capacity:

Notification of incapacity shall be made to the patient if the patient can comprehend the information. Findings of incapacity

shall be given to the health care agent or surrogate. To a reasonable degree of medical certainty (check one):

The patient has decisional capacity.

The patient lacks decisional capacity due to:

__________________________________________

The duration of incapacity is expected to be:

temporary

prolonged

permanent.

Physician Name ________________________________ Signature ______________________

Date_________________

Concurring Health Care Provider Name _____________ Signature ______________________

Date_________________

Medical Condition:

Treatment would impose an extraordinary burden and to a reasonable degree of medical certainty the patient

has (document one for patients without capacity and without a health care agent):

An illness or injury which is expected to cause death within six months regardless of treatment.

Permanent unconsciousness.

An irreversible or incurable condition such that treatment would impose pain, suffering or other burden.

Physician Name ________________________________ Signature ______________________

Date_________________

Concurring Physician Name _______________________ Signature ______________________

Date_________________

Do Not Resuscitate Dnr Form